Registering for summer camp

Step 1 - Register

*Please hit "submit waiver" at the bottom after filling out form and before going to step 2. Thank you.

1st Child's Name *

Birthdate *

Birthdate

MM

DD

YYYY

Is your child 6 years old or older? *

(age requirement is 6+)

IF SIGNING UP MORE THAN ONE CHILD, PLEASE FILL OUT INFORMATION BELOW: (NAME, GENDER, BIRTHDATE)

2nd Child's Name

Birthdate

Birthdate

MM

DD

YYYY

Is your child 6 years old or older?

(age requirement is 6+)

Parent or Guardian Information

Primary Contact Name *

Primary Contact Name

First Name

Last Name

Email Address *

Phone Numbers (Home, Cell, Work) *

List primary contact's phone numbers.

Home Address *

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer *

Emergency contact person *

Emergency contact phone *

Emergency contact phone

(###)

###

####

Authorized pickup *

List names and phone number of people who you authorize to pickup your child (other than you)

Emergency Medical Information

PERMISSION IS GIVEN TO ONE WITH HEART FOR THE FOLLOWING: IN AN EMERGENCY, ONE WITH HEART HAS MY PERMISSION TO OBTAIN MEDICAL TREATMENT FOR MY CHILD, CALL AN AMBULANCE OR TRANSPORT MY CHILD TO ANY AVAILABLE PHYSICIAN OR HOSPITAL AT MY EXPENSE, WITH THE FOLLOWING RESTRICTIONS (IF APPLICABLE) MY CHILD MAY BE GIVEN MEDICATION. I UNDERSTAND THE MEDICAL AUTHORIZATION FORM MUST BE COMPLETED AND SIGNED PRIOR TO ADMINISTERING. I UNDERSTAND I MUST CLEARLY COMMUNICATE ANY MEDICATION ADMINISTRATION INSTRUCTIONS AND PERMISSION TO OWH STAFF PRIOR TO CAMP. MY CHILD MAY PARTICIPATE IN ONE WITH HEART POEKOELAN CENTER FIELD TRIPS. I UNDERSTAND VAN OR PUBLIC TRANSPORTATION MAY BE USED. MY CHILD MAY PARTICIPATE IN SWIMMING OR OTHER WATER ACTIVITIES. MY CHILD MAY BE PHOTOGRAPHED FOR WITHOUT ANY PERSONAL IDENTIFIERS IN MARKETING MATERIALS AND MEDIA PROMOTING THE SCHOOL.

Child's Physician *

If signing up more than 1 child, please put other child’s info in also.

Physician's Address

Physician's Phone *

Physician's Phone

(###)

###

####

Allergy Information *

Date of last Tetanus *

Child's Dentist *

Dentist's Address

Dentist's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Hospital

Health Insurance Company and Phone *

Parent or Legal Guardian Signature * *

How did you hear about us? (Facebook, Google, Yelp, Etc) *

GET UPDATES AND INFORMATION ABOUT ONE WITH HEART BY SIGNING UP FOR THE E-NEWSLETTER

I would like to know more about: (Check all that apply)

Adult Pukulan Kung Fu Classes

Adult Shaolin Kung Fu Classes

Self-Defense for Women and Teen Girls

Kids Pukulan Kung Fu Classes

Kids Self-Defense (No Go Yell Tell)

Kids After School Programs and Day Camps

Kids Summer Camps

Hati Hati Healing Energy Treatments

Step 1 - Complete — Thank you!

Step 2 - Click on link below to add camps to cart

*Please hit "submit waiver" above after filling out form and before going to step 2. Thank you.